Finding into death of Robert Humphreys
Deceased
Robert Michael Humphreys
Demographics
71y, male
Date of death
2015-09-07
Finding date
2018-11-19
Cause of death
Aspiration in setting of paralytic ileus in patient in convalescent phase of abdominal aortic aneurysm repair
AI-generated summary
A 71-year-old man died from aspiration complicating prolonged paralytic ileus on postoperative day 9 following open abdominal aortic aneurysm repair. Despite clinical signs of persistent ileus (vomiting, abdominal distension, abnormal bowel movements), the surgeon Dr C. did not reinstate bowel rest, nasogastric tube, or radiological imaging. He declined a medical registrar review when contacted on day 8 evening despite family concerns about deterioration. The coroner found the postoperative management suboptimal. Radiological examination on day 5-7 would have revealed ongoing ileus, warranting nasogastric tube reinsertion and bowel rest, which would have likely prevented aspiration. Key clinical lessons: maintain vigilance for evolving paralytic ileus despite signs of bowel recovery; reassess regularly with imaging when signs persist; involve senior review and multidisciplinary input for complex post-operative cases; document clinical observations thoroughly.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Prolonged paralytic ileus not recognized as ongoing
- Failure to reinstitute nasogastric tube despite recurrent vomiting
- Lack of radiological investigation to confirm ileus status
- Failure to arrange medical review despite family and nursing concerns
- Acute renal injury contributing to ileus
- Inadequate postoperative documentation by surgeon
- Insufficient escalation of clinical concerns
Coroner's recommendations
- Executive Director of Medical Services and Clinical Governance at Cabrini Health should confer with interested parties and provide further direction to nursing staff concerning when and in what circumstances a patient whose presentation following vascular surgery should be made the subject of a discretionary MET call by nursing staff, particularly where threats to patient wellbeing are specific to physiological conditions not measurable by vital sign changes
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